QD: News Every Day--Better handoffs needed from ERs back to primary care

Improving handoffs from the emergency room back to the primary care physician will require changing how electronic health records are used, better reimbursement to both the hospital and ambulatory doctors, and malpractice reform, according to a study.

Haphazard communication and poor coordination can undermine effective care, according to a new research conducted by the Center for Studying Health System Change. Researchers conducted 42 telephone interviews between April and October 2010 with 21 pairs of emergency department and primary care physicians, who were case-matched to hospitals so the perspective of both specialties working with the same hospital could be represented.

Among the findings in the report, telephone communication was essential in some cases, but particularly time-consuming. Both emergency and primary care physicians reported successful completion of each telephone call often required multiple pages and lengthy waits for callbacks. While placing and receiving telephone calls might seem straightforward and quick, providers said each small action multiplied across dozens of patients can become a daunting burden, with little immediate reward or reimbursement.

Faxes and e-mails can be reviewed at a provider's convenience but do not provide an opportunity to ask questions. Physicians had little confidence that faxes were carefully reviewed by their intended recipient and often reported that faxed records were poorly organized and difficult to decipher. "What used to be a few pages is now 20-30 pages," said one primary care provider during an interview.

While shared electronic medical records are valuable tools for billing and liability documentation, they are not designed to offer a rapid overview with the level of detail that could help an emergency provider direct care.

Larger groups and more elaborate cross-coverage systems means that emergency physicians are less likely to speak with a physician who has direct knowledge of the patient. And, while rising hospitalist use and the growth of larger primary care groups help office-based providers decrease their call responsibilities, the result is fewer interactions between office-based and hospital-based physicians. Many emergency physicians reported that they had no venues for ongoing collaboration with primary care practices in their community.

The authors further noted that even if practical barriers are removed, liability concerns divide providers because emergency and primary care physicians have different constraints and fundamentally different assumptions regarding patients' reliability and resilience.

The authors noted that physicians aren't reimbursed for communicating, and that reimbursing for this task is an option. But better policies might include changes in meaningful use criteria for electronic medical records, payment incentives that reward both primary and emergency providers for managing utilization, and malpractice liability reform.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.
ACP Internist
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